Depression in Children (cont.)

Roxanne Dryden-Edwards, MD

Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

What should parents do if they suspect that their child is depressed?

Family members and friends are advised to seek mental-health evaluation and
treatment for the depressed child. Family members may consult with the child's
primary-care doctor or seek mental-health services by contacting one of the
resources identified below. Once the depressed child is in treatment, family
members can help encourage good mental health by gently encouraging him or her
to adopt a healthy lifestyle. Examples of that include encouraging the child to
maintain a healthy diet, get adequate sleep, regular exercise,
remain socially engaged and to participate in
appropriate
stress-management activities. Family can be helpful to the depressed
child by discouraging their loved one from engaging in risky behaviors.

What is the treatment for depression in children?

If symptoms indicate that
your child is suffering from clinical depression, the health-care professional likely will
recommend treatment. Treatment may include addressing any
medical conditions that cause or worsen depression. For example, an individual
who is found to have low levels of thyroid hormone might receive hormone
replacement with
levothyroxine (Synthroid). Other components of treatment may be
supportive therapy, such as changes in lifestyle and behavior, psychotherapy,
complementary therapies, and may include medication for moderate to severe
depression. If symptoms are severe enough to warrant treatment with medication,
symptoms tend to improve faster and for longer when medication treatment is
combined with psychotherapy.

Most practitioners will continue treatment of major
depression for six months to a year in order to prevent a reoccurrence of
symptoms. Treatment for children with depression can
have a significantly positive effect on the child's functioning with peers,
family, and at school. Without treatment, symptoms tend to last much longer and
may not improve. In fact, they may get worse. With treatment, the chances of
recovery are much more likely.

Psychotherapy

Psychotherapy ("talk therapy") is a
form of mental-health counseling that involves working with a trained therapist
to figure out ways to solve problems and cope with depression. It can be a
powerful intervention, even producing positive biochemical changes in the brain.
Two major approaches are commonly used to treat childhood depression: interpersonal psychotherapy and cognitive behavioral therapy. In general, these therapies take weeks to months to complete. Each
has a goal of alleviating the symptoms. More intensive psychotherapy may be needed
for longer when treating very severe depression or for depression with other
psychiatric symptoms.

Interpersonal therapy (IPT): This helps to alleviate
depressive symptoms by helping a child who suffers from depression develop more effective skills for
coping with their emotions and relationships. IPT employs two strategies to achieve these goals:

The first is educating the child and family about the nature of depression. The
therapist will emphasize that depression is a common illness and that most
people can expect to get better with treatment.

The second is defining problems (such as abnormal grief or interpersonal
conflicts). After the problems are defined, the therapist is able to help set
realistic goals for solving these problems and work with the depressed child and
his or her family using various treatment techniques to reach these goals.

Cognitive behavioral therapy (CBT): This has been found to be effective as part
of treatment for childhood depression. This approach
helps to alleviate depression and reduce the likelihood it will come back by
helping the child change his or her way of thinking about certain issues. In
CBT, the therapist uses three techniques to accomplish these goals.

Didactic
component: This phase helps to set up positive expectations for therapy and
promote the child's cooperation with the treatment process.

Cognitive component: This helps to identify the thoughts and assumptions
that influence the child's behaviors, particularly those that may predispose the
sufferer to being depressed.

Behavioral component: This employs behavior-modification techniques to
teach the child more effective strategies for dealing with problems.

Medications

The major type of antidepressant medications prescribed for children is the
selective serotonin reuptake inhibitors (SSRIs). SSRI medications affect levels
of serotonin in the brain. For many prescribing doctors, these medications are
the first choice because of the high level of effectiveness and general safety
of this group of medicines. Examples of these medications are listed here. The
generic name is first, with the brand name in parentheses.

Only Prozac and Lexapro are approved by the Food and
Drug Administration (FDA) for the treatment of childhood depression and only in
ages 8 years and above. Any other medications used to treat this illness in
children, or the use of an antidepressant in younger children, is therefore
considered to be being used "off label."

Although FDA approved for use in teens with schizophrenia rather than for
the treatment of depression, atypical neuroleptic medications like aripiprazole
(Abilify) and risperidone (Risperdal) are sometimes prescribed in addition to an
antidepressant in children who either suffer from severe depression, fail to
improve after receiving trials of different antidepressants in addition to, or
instead of, an antidepressant in children who suffer from bipolar disorder.

Non-neuroleptic mood-stabilizer medications are also sometimes used with an
antidepressant to treat children with severe unipolar depression who do not
improve after receiving trials of different antidepressants. These medications
might also be considered in addition to or instead of an antidepressant in
children who suffer from bipolar disorder. Examples of nonneuroleptic mood
stabilizers that are used for this purpose include
divalproex acid (Depakote),
carbamazepine (Tegretol), and lamotrigine (Lamictal). Of the non-neuroleptic mood
stabilizers,
lamotrigine (Lamictal) seems to be unique in its ability to also treat unipolar
depression effectively by itself as well as in addition to an antidepressant.
However, it is only used in people 16 years of age or older due to potentially
serious side effects.

Atypical antidepressant medications work differently than
the commonly used SSRIs. The following medications might be prescribed when
SSRIs have not worked:
buproprion (Wellbutrin), venlafaxine (Effexor),
duloxetine (Cymbalta), or desvenlafaxine (Pristiq).

About 60% of children who
take antidepressant medication get better and are thought to be highly
suggestible to improve (placebo effect). It may take anywhere from one to six
weeks of taking medication at its effective dose to start feeling better. The
prescribing physician will likely assess the depressed child that is receiving
the medication soon after it is started to see if the medication is being well
tolerated and if symptoms have begun to improve. If not, the doctor may adjust
the dose of the medication or prescribe a different one.

After symptoms begin to improve, the prescribing doctor will likely
encourage the family of the depressed child to continue administering the
medication for six months to a year since stopping the medication too soon may
cause symptoms to return or worsen. Some people need to take the medication for
longer periods of time to keep the depression from returning. Stopping abruptly
may cause the depression to return or for withdrawal effects to occur, depending
on the medication that is being taken.

The side effects of antidepressant
medications vary considerably from drug to drug and from person to person.

In rare cases, some people of all ages have been thought to have
become acutely more depressed once on the medication, even attempting or
completing suicide or homicide. Children and teenagers are thought to be
particularly vulnerable to this rare possibility. However, when considering this
risk, it is important to also consider the risk of the potential serious
outcomes that can result from untreated depression.

Alternative treatments

Several nonprescription herbal supplements like St. John's wort and dietary
supplements like
vitamin C are used to treat depression.
Little is known about the safety, effectiveness, or appropriate dosage of these
remedies, although they are taken by thousands of people around the world.

A
few of the best-known alternative remedies continue to be studied scientifically
to see how well they work, but to date, there is little evidence that herbal
remedies effectively treat moderate to severe clinical depression.

Medical professionals usually are hesitant to recommend herbs or dietary
supplements, particularly in children, because they are not regulated by the
U.S. Food and Drug Administration (FDA), as prescription drugs are, to ensure
their purity and quality.